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                                                                                   For more information, to register online or make a donation, visit
                                                                                                                            Featuring the Famous Golden Stick Challenge!

                                  RAcE                                                                                      Event Date                 Saturday, April 16, 2011

                                                                                                                            Location                   Charlottesville High School
                                                                                                                                                       1400 Melbourne Rd, Charlottesville
Saturday                                                                                                                    Fees                       $20 pre-registration, $25 day of race
april 16, 2011                                                                                                                                         Proceeds benefit the Virginia Institute of Autism
                                                                                                                                                       (Groups of 10 or more, please register by April 1)
                                                                                                                            Start Times                Registration/Check In 6:45 – 7:30 am on race day
                                                                                                                                                       Race starts at 7:45 am sharp
                                                                                                                                                       (Early Check In, Friday, April 15, 4-6 pm at VIA)

                                                                                                                            Awards                     Free custom-designed t-shirt to all participants
                                                                                                                                                       (Register by April 1 to guarantee your t-shirt and preferred size)
Kids’ 1/4 Mile Race                            Autism is now more common than childhood                                                                Overall, age group, and top fundraiser prizes
as part of the Kids’                           cancers, Down Syndrome and childhood
Triple Crown Series,                                                                                                        Course Profile             Scenic park, neighborhoods;
                                               diabetes combined! Established in 1996, the
Open to Ages 3 - 12                                                                                                                                    Enjoy this year’s modified course, starting and
                                               Virginia Institute of Autism (VIA) operates                                                             finishing at Charlottesville High School!
                                               a private, not-for-profit school and resource                                                           map online at

                                               center providing services to children with                                   Parking                    Convenient parking at Charlottesville High School
     Family Friendly!
                                               autism and their families. Please support this
                                                                                                                            Reminders                  Registrations now accepted online,
                                               worthwhile cause by joining us for a fun morn-
                                                                                                                                                       Avoid the race day lines by checking in early on
                                               ing of running and walking. Families, children                                                          Friday, April 15 from 4-6 pm at VIA
 An official Kid’s Triple Crown event          and adults with disabilities are welcome!

  A special thanks to our sponsors:

Please return bottom portion to (checks payable to VIA):                                      VIA, 1414 Westwood Rd, Charlottesville, VA 22903 or
                                                                                              drop off at the Ragged Mountain Running Shop by noon on April 15, 2011
*EACH participant must submit an individual signed registration form. A parent or guardian must sign for runners under 18.

Name: ____________________________________ Address: _____________________________________________________________________

Phone: ___________________ E-mail: ______________________________________ Age on Race Day: _____ Gender:                                                                                                  Male           Female

T-Shirt:           Small             Medium                Large             XL           XXL            Kid’s Large
I am participating in the lacrosse “Golden Stick” team challenge (see letter from Race Director for details) and represent:
   Albemarle               Charlottesville              Cville Catholic               Covenant              Monticello              St. Anne’s-Belfield                Western Albemarle                   Other___________

     Unfortunately, I will be unable to participate, but I would like to make a donation!
     I am paying with:                   Cash             Check (payable to VIA)                         Credit Card (Visa or Mastercard)
                                     Credit Card: __________________________________________ Exp. Date: __________
                                     Authorization Signature: ____________________________________________________
                                                                                                                                                                                                      Kids’ Race
     I am participating in honor of ___________________________________________________
Amount enclosed: Entry fee: $_______ + Donation to VIA $_______ = Total $__________
I know that running is a potentially hazardous activity. I should not enter and run unless I am medically able and properly trained. I agree to abide by all decisions of the race officials relative to my ability to compete and
walk or run successfully. I assume all risks associated with walking or running in this event, including but not limited to falls, contact with other participants, the effect of weather, including high heat and humidity, traffic
and the conditions of the road, all such risks being known and appreciated by me. Having read this waiver and knowing these facts and in consideration of your accepting my entry, I, myself and anyone entitled to act
on my behalf, waive and release the Virginia Institute of Autism, the city of Charlottesville and all Sponsors, their representatives and successors from all claim or Liabilities of any kind arising out of my participation in this
event. In consideration of the safety of all participants, I understand that absolutely no baby joggers, baby strollers, headphones, animals on leash, skateboards, skates, rollerblades or bicycles are allowed on the course.
In addition I understand that if the race is canceled by circumstances beyond the control of the organizers, my entry fee will not be refunded. I grant permission to all the foregoing to use photographs, motion pictures,
recordings, or other record of this event for any legitimate purpose.

Signature*: ________________________________________________________ Date: _______________
                                         *if under 18, please have a parent or guardian sign

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